3434 W BRADY AVE (3)Permit Types
BLD ELE MEC I PLM
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''` `' etmlt Number: BLD2023-01231
Issued: 03/14/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 7
Site Address: 3434 W BRADY AVE B, ANAHEIM, CA 92804
Legal Description: N TR 1098 BLK LOT 61
APN:07928305
CITY OF ANAHEIM
BUILDING DMSIONLVD.
200 S. ANAHEIM B.
(714) 765 - 5153
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code. for the performance of the work for which
this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. Policy No.: Expiration Date:
Name of Agent
Phone No.:
4,-- 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
worker's compprisetion laws of California, and agree that, O I should become subject to the worker's compensation provisions of Section 3700 of the
o shall forthwith comply with those provisions.
Sign Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my li a is in force and effect.
Contractor WriaGre Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
869173 12/31/2023 A. B